The Physicians’ Alliance for Total Refusal of Euthanasia would like to thank the members of the Health and Social Services Committee for having invited them to meet them and for giving them the opportunity to voice their reaction to the tabling of Bill 52, An act concerning end-of-life care.The Alliance was born in 2012 and already has 593 physician members: 473 from the four corners of Quebec, working in a great variety of medical fields, and 120 from elsewhere. Extremely concerned with the evolution of the end-of-life debate, they are horrified at the idea that killing one’s patients may one day become legal. That is why they have signed our Declaration "Caring, not killing." More than 10,000 citizens have also signed a form to support their doctors and to state their opposition to both futile medical care and the legalisation of euthanasia or assisted suicide and their desire to promote palliative care. A list of their names is appended to this brief.We are here today on behalf of all the ordinary doctors who are very worried about the effect on their patients in the event that Bill 52 is adopted. We believe that this bill is unworthy of Quebec and must be abandoned. Many more humane solutions to the widespread fear of a painful death are available...Of two mindsIf at the outset we were pleased to note the important place given to palliative care in Bill 52, we rapidly became disillusioned by noticing that the legislator has misrepresented palliative care by including in it medical aid in dying – a euphemism used to hide the deadly reality of euthanasia. In fact, even though medical aid in dying has not been defined, one needs only to read article 63 to understand that it consists of "administering the drug or substance… to obtain medical aid in dying." – A definition which strangely resembles that which is given for euthanasia by the American Academy of Pain Medicine: "The intentional administration of a lethal substance causing death". For its part, The World Health Organisation (WHO) has clearly established that palliative care does not accelerate or impede the natural moment of death.Bill 52 also enshrines the universal right to obtain euthanasia (medical aid in dying), but it subjects the right to obtain palliative care to the limits of our establishments’ human, material and financial resources (Art 5). As we know, euthanasia costs little while palliative care requires personnel and infrastructure costs that are far from being negligible. This is why we are affirming that this project promotes the marginalisation of palliative care, not to say its progressive disappearance. This reflection of doctor Jean-Marc Lapiana, director of la Maison de soins palliatifs in Gardanne (France), says it all:

"If we are opposed to the legalisation of euthanasia, it is not for moral or religious reasons, but because if we had the legal possibility to kill our patients, I and the team with whom I work would not give ourselves all the trouble that we do to find solutions for difficult situations." (p.59, 60) 1

With all due respect, it is important to underline here that the majority of people who are promoting Bill 52 are not doctors. It is the case for, among others, the honorable Véronique Hivon and of Me Jean-Pierre Ménard. As to doctors who speak on behalf of The Collège des médecins and the medical Federations, many work little or not at all in clinical medicine with patients who are incapable or at the end of life. Few are treating physicians for vulnerable patients in acute or long term care hospitals; Dr. Barrette, for example, is a radiologist and D. Yves Robert has been working full time for the CMQ for many years. For this reason they minimize the dangers of harm and abuse.On the other hand, the doctors who work in the trenches and who accompany the sick and dying and their families day after day know very well what the end of life is about. Because they clearly see the risks related to euthanasia, 90% of palliative care physicians are fiercely opposed to the legalisation of this practice.In a recently published article in La Presse (September 7, 2013), Dr. Balfour Mount, founder of palliative care in North America, and Drs. Manuel Borod and Bernard Lapointe, recognized specialists in palliative care, sought to provoke reflection with these words:

"If there were a project to build a bridge and 90% of the engineers thought its design was dangerous, it would provoke a public outcry. So, why is Bill 52, which is opposed by a great majority of workers in palliative care, not provoking the same indignation?"

What is so urgent?Another question must be asked: what urgency is there to enact such radical legislation? There is so much to do before even thinking of legalising euthanasia: increase access to palliative care; improve treatment in hospitals where patients often feel disoriented and abandoned; improve long-term care and facilitate access to LTC centres; give doctors and other health care workers solid training in pain control and end-of-life treatment and decision-making; help patients to foresee these questions (ex.: advance directives), etc.Killing a patient is much easier than treating and accompanying someone until his death comes naturally and peacefully. It is easier than speaking with the patient and his or her family members in order to address their fears. It is easier and less expensive than making quality palliative care available to all who need it. It is easier than making long-term care accessible and humane. It is easier than curing what is ailing in the health care system.Face to face with the anguished patient If some surveys reveal that Quebecers are largely in favour of medical aid in dying, it’s because confusion reigns about rights that we already have: the right to refuse or withdraw treatment, the right to refuse nutrition, hydration or ventilation. Nobody wants to be the victim of over-aggressive therapy. Some would rather die because they are afraid of suffering uncontrollable pain, of being old and sick, afraid of the health care system, that big machine where they feel so helpless, and afraid of a traumatic death.Why not tell them that medicine has the capability today to control almost all physical pain and that palliative sedation is already available for the few other cases? 2 Not terminal sedation – a lethal act that voluntarily provokes death in little time, but palliative sedation that is titrated to ensure the patient’s comfort Face to face with an anguished patient who has lost his self-esteem, who is ashamed of his worsening physical appearance and who feels he is a burden for others, would you have us say to him by our actions and our attitude: "You’re right : you’re worthless. Since you feel that your life is now useless and that you cost too much to the health care system, and since you are lonely and abandoned, we’ll help you to die quickly if you ask us to?" Or would you rather we rebuild his self-confidence and comfort him during the time he has left to live by daring to listen to him and to overcome our own fears?Ineffective safeguardsWe know to what extent a person can become vulnerable and susceptible to influence when he is sick. Let us have no illusions: if we legalise euthanasia, there will be instances of euthanasia without adequate consent. Patients may perhaps give their consent, but only out of fear of suffering, or under pressure of from a third party, or because of guilt at taking up a much needed hospital bed or of being a burden to one’s family.These scenarios are occurring as we speak in Belgium and in the Netherlands. It is untrue that everything is going smoothly there. In Belgium, where so-called strict safeguards (very similar to those proposed by Bill 52) were put in place at the very moment euthanasia was legalized; there is currently a request to broaden access to include minors and people with dementia. But without a doubt, the most tragic occurrence is the change of mentality in that country: death by euthanasia is no longer considered an exception, but a right.In 2009 The WHO pointed a finger to the Netherlands, concerned by the high number of acts of euthanasia performed there:

"Everything is operating as if legalisation increases the permissibility and tolerance for the act of euthanasia among both doctors and patients. In brief, once euthanasia is institutionally and officially approved and practiced, it develops its own dynamic and resists all surveillance procedures that are supposed to contain it."

As doctors we know…Bill 52 justifies euthanasia of a patient who suffers from "constant and unbearable physical or psychological pain which cannot be relieved in a manner the person deems tolerable." As doctors, we know there is no scientifically acceptable definition for unbearable pain; there is even less of a consensus for psychological pain. Do we want to endorse just about any reason given subjectively by the patient in order to bring about his death? If it is left to the patient to decide whether the treatment proposed is “tolerable”, we will be entrusting a dangerous weapon to someone who is extremely vulnerable, fragile and prone to manipulation by others.As doctors, we know that once we abolish the prohibition to kill, the reciprocal trust that is the foundation of the patient-doctor relationship will be shaken, not to speak of the adverse effect on the psyche of the doctor who will give death in a premeditated fashion, with the approval of the law. Euthanasia desensitizes the doctor confronted with the act of inflicting death, and places him consciously in a situation of ethical suffering, torn between beneficence (accompanying the patient without aggressive therapy) and autonomy (putting an end to the life of a patient upon request).Dr. Bernard Lapointe summarizes the danger well:

"We doctors, know that the power that we have is dangerous. What will happen the day our laws authorize us to kill? We will lose the trust of our patients, which is the foundation of our work. Without this trust our profession will be destroyed." (p.79)

As doctors, we know that Bill 52 offers nothing but an illusion of control, of choice and of dignity. In fact, to advance death is not to conquer it. Nothing and no one can effectively control death. It is the doctor who will decide when and how the patient will die; paradoxically, the supposed absolute autonomy of the patient will become the springboard for the reinforcement of medical paternalism. The doctor will give the "incurable" diagnosis of incurability, will validate the "intolerable pain", will decide on the decision-making capacity of the patient, will fill-in the pre and post-mortem forms, and will perform the act causing death.With regard to choice, a question must be asked: what choice is really free, especially in the context of choice in one’s own death? Choosing to die is always an illusion, because that choice is but a symbolic act facing an implacable reality: we will all die. As to "taking control" and feeling that being euthanized gives dignity to one’s death, we must remind ourselves that death destroys the person, source of dignity. The dying person is always a living being, a person with dignity and the "respect due to each human being because of the simple fact that he is human" (Paul Ricoeur). "Dignity cannot be reduced to personal convenience; it is not the result of how one is seen by others, nor can it be confused with the self-determination." (Jacques Ricot, 2006).As doctors, we fear…As doctors, we also fear an exploitation of psychiatrists who will be caught in the trap of a double allegiance: loyalty towards the patient versus the task that will be conferred on them by the State. No scientifically recognized criteria exist to evaluate the specific capacity of a person to consent to receive death upon request. No court decision has validated the criteria for these specific cases.As doctors, we are dismayed by the fact that Bill 52 makes the objection of conscience impossible. Yes, we can refuse to euthanize a patient, but we will be obliged to refer them to the DPS who will find a doctor willing to perform this act. This complicity is a evident negation of our freedom of conscience. And what about the obligation that will be imposed upon institutions to collaborate in the setting up and the execution of the program? As doctors, we refuse…It seems as if Quebec is searching at any cost to become a forerunner in this domain in Canada, despite the fact that 60% of briefs submitted to the Special Commission on the question of dying with dignity were opposed to euthanasia, as were the vast majority of doctors who expressed an opinion.As doctors, we refuse the violence of euthanasia, the ultimate abuse against the most vulnerable. We wish to recall, in the words of Claude Évin, socialist Health minister of Michel Rocard (1988-1991), and of professor Puybasset, chief of neuroreanimation at the Pitié-Salpêtrière, that legalising euthanasia in practice becomes the

"requirement of caregivers to actively inflict death, which is to stop the heart of the sick to treat his suffering […] In reality it is an extremely violent gesture that does not comfort the end of life for patients and their families, but, to the contrary, multiplies situations of pathological grief and generates a division among the care giving teams. […]

"Let us call things by their name. To be in favour of euthanasia is to advocate legalizing the lethal injection of barbiturates and of curare. (…) To present this as a progressive idea may have fooled some people in the 1970s when the tools available to control pain were limited and doctors were enclosed in their omnipotence, but now there is no doubt the concept has become archaic."

Killing is not care. Killing a patient, even upon his or her request, is grave ethical misconduct in a so-called civilized society.As doctors, we finally affirm that euthanasia is an injustice. Not only toward the sick, their families, caregivers and society, but also for the authorities (doctors, hospitals, government) who will be placed in conflict of interest with patients when inflicting death becomes a means to save effort, time and money.Warnings from a psychologistWe can’t ignore the dramatic impact that the choice to euthanize a patient will have on us. Marie de Hennezel, a French psychologist, psychotherapist and author, eloquently speaks of this:

"Many doctors differentiate for ethical reasons between relieving pain, at the risk of shortening life, and actively stopping life. We are told that this difference is an illusion, even hypocritical, since the result is the same. Of course, it is, but not the experience of the physician: in one case, he feels that he has not betrayed his vocation that is to heal; in the other case, he feels that he has executed his patient. I do not see any reason to neglect this subjectivity of health professionals."

"As a psychologist, I have been for the past twenty years the confidante of many doctors and nurses having euthanized a patient. I can bear witness to the violence that this radical act represents: it is a source of prolonged nightmares and some, haunted by the last look of the patient to whom they have given death, are dragged into unending depressions. We have to become aware of the weight that this can represent for them" (p. 78-79).

Marie de Hennezel continues:

"Why can’t health professionals say to the sick how his request for death is upsetting to them and violates them? Each time I hear a pro-euthanasia activist express offence at a doctor "confiscating" from the dying the liberty to choose the moment of death, I feel like asking him if he sincerely thinks that the dying have all the rights, notably the right to do violence to the doctor by forcing him to kill him or blaming him for not doing so. The simple fact of being an elderly or terminally ill person does not give the right to burden another with guilt or to require from him an act that will scar him permanently" (p. 83-84).

The most terrible violenceSome fear that the members of the Health and Social Services Committee will let themselves be influenced by the "do-gooders," imposing the so-called "ideological excesses," "false representations" and "religious orthodoxy" of their opposition to the bill. As for us, who have founded our opposition to Bill 52 and to all eventual legalisation of euthanasia and assisted suicide on our unconditional respect for the inalienable dignity for each human being, we prefer to believe in your open-mindedness and discernment and to call upon your humanity.We dare to hope that you will be able to resist to the pressure tactics of a "small number of intellectuals in good health, who are obsessed by their desire to master their death, and highly skilled at playing on the legitimate fears of their contemporaries to obtain widespread support for the individualistic claims" (p. 37)We are convinced, as was former French president François Mitterrand, that "no one can take someone else’s life in a democracy". The ban on homicide, even out of compassion, belongs to the common moral conscience of all cultures and all times; it must not be confused with religion. Besides, all the doctors performing euthanasia whom we met in Belgium insisted on affirming that this act is more difficult than any other they have performed in their lives. Dr. Luc Sauveur even adds that causing the death of a patient constitutes the most terrible violence that he has ever witnessed.Let us remind ourselves of the words of Dr. Dominique Lossignol, promoter of euthanasia in Belgium, who said: "The patient, when he makes a request for euthanasia, generally has his pain well controlled. Understand me well. If you can imagine someone in pain asking me: "Doctor, help me to die, I have too much pain" and that I acquiesce to his request without first alleviating the pain, I commit a grave act of malpractice." Bill 52 goes even further (article 7) in permitting a patient to request euthanasia even if he has refused treatment to relieve his pain, such as palliative care. If the Quebec National Assembly adopts this bill, while thousands of Quebecers end their lives with unrelieved pain because of a lack of services and lack of training for healthcare professionals, it will have committed a grave act of malpractice.We uphold that it is not the right of the state to organise the putting to death of citizens who ask to die. Such a decision would contradict the great Quebec values of solidarity and equality. Of course, "it is easier, and more economically viable, to legalise lethal injection than to grant some time, attention and support to the other." But a century from now, "we will perhaps look back and say that we were as blinded as if we were in a totalitarian regime." 3Unheard-of scenarioIf, at the same time as Quebec seeks a Charter of values to ensure unity and social peace, she takes the path of medical killing, we could say that we have definitively rejects the great humanistic values which are at the basis of our democracy.While ardently wishing the death of Bill 52, we propose in our conclusion an unheard-of scenario in the event that Quebec society decided to authorise euthanasia:

"Since it is a society’s wish, why not ask members of society to participate? Why not ask each of us, in whose name this right will be given, to participate in this act of euthanasia? A citizen drawn at random, for example?" 4

We are however convinced that the majority of Quebecers will say "no" to physician-inflicted death if only they could overcome the confusion in which they are being maintained, and if they could count on the doctors skilled in the latest pain control methods. That is why we are inviting you, as well as all our political representatives, to reflect on ways to truly humanize health services and hospitals – so we can die with dignity – without seeking to anticipate or to accelerate death for people who suffer because they live in a world where they are no longer wanted.The author-composer Dan Bigras wrote recently:

"Suffering is a dirty word. We don’t treat it, we clean it up"

If this bill is adopted, it will be proof that what we want is to rid our society of this dirty suffering that we don’t want to accompany to the end. Palliative cultureBecause we are convinced that a civilized society must ensure the security of all its citizens until their natural death, the Alliance joins the World Medical Association, the American Medical Association and the Canadian Medical Association to affirm loud and clear that doctors should never collaborate in an act of euthanasia. This gesture could never be qualified as a "care" since it contradicts the fundamental ethical principles of medical practice.For all the reasons brought forth in this brief, we are asking the Quebec Government to withdraw Bill 52. There is no doubt in our minds that the solidarity manifested by our people with regards to the most downtrodden and the most vulnerable – in particular by suicide prevention – will inspire the legislator to table another bill which, respectful of the true nature of palliative care, will ensure it is implemented throughout Quebec. In this way all citizens shall be reassured that their doctors will seek neither to unduly prolong their days nor to shorten them. Never will they kill them. With compassion, they will accompany them to the end accepting their death when the time is come.Because the medical vocation is to treat, to heal sometimes, to relieve often and to comfort always while preserving life, we wish that the palliative culture that is already adopted by certain establishments become the general rule so that all doctors and caregivers learn to accompany the dying in with humanity and compassion. Death is nobody’s failure. It is the reality of our shared humanity.The refusal to inflict death must remain an impassable barrier in a democratic Quebec.

"Are we aware of the way we look at the damaged in life, of the force of contempt we convey, of the despair we engender in the heart of the sick and the aged that makes them, at the end of the race, prefer dying to living? This preference for death, we have baptised «dying with dignity» (…) The real dignity is that which is experienced by a fragile person for whom we care with tact and gentleness, and who feels through our gestures and looks that he still holds a place in the world of humans."

This brief for the Physicians’ Alliance for Total Refusal of Euthanasia was presented to the Health and Social Services Committee by the following people:

D. Catherine Ferrier, family physician and assistant professor of family medicine at McGill University. She has been working for 30 years in the geriatric clinic of the McGill University Health Centre(MUHC) where she sees patients suffering from problems related to advanced age, especially dementia, and where she directs the competency assessment clinic. She worked in primary care family medicine in Ville St-Pierre for twelve years.

D. François Primeau, geriatric psychiatrist and member of the research ethics committee at the Hôtel-Dieu de Lévis, and associate clinical professor at Laval University. He has many years of clinical and teaching experience in geriatric psychiatry and in ethics. Recognized as one of the founders of the subspecialty of geriatric psychiatry by the Royal College of Physicians and Surgeons of Canada, he was named fellow of the Canadian Psychiatric Association in 2012 particularly for his involvement in ethics.

D. Serge Daneault, physician and researcher in the palliative care unit of Notre-Dame Hospital (CHUM), is an associate professor at the Université de Montréal faculty of medicine. His internationally recognized research on suffering in relation to health services led him to Belgium in October 2012, where he visited French-speaking areas where euthanasia is practised.